It's been a decade since Tennessee last updated immunization requirements for children. An enhanced schedule, which became official at the end of 2009, impacts those enrolling in day care, pre-school, elementary/middle school and college.

Online Resources for Providers

The Tennessee Department of Health has included a number of resources online to assist providers in understanding and communicating the new immunization requirements. An overview is available at: http://health.state.tn.us/CEDS/required.htm. Detailed guidance for healthcare providers on the new rules and certificate is available at the Tennessee Web Immunization System site at http://health.state.tn.us/twis. The site includes an instructional packet, Power Point training module, answers to frequently asked questions and sample versions of blank school certificates. To download a child's certificate, registered users of the state immunization registry (TWIS) may log in and then click on "blank forms" in the document section or print a certificate for a specific child directly from the child's registry record. Interested healthcare providers can register to use TWIS at no cost by following instructions on the TWIS website.

Kelly Moore, MD, MPH, medical director for Tennessee's Immunization Program, said the new requirements bring the state into alignment with the recommended schedule of the Centers for Disease Control and Prevention (CDC). She noted a lot has changed in vaccines since the state last updated regulations in 2000.

Most of the new requirements had an effective date of July 1, 2010, which means children must have updated records for the new school year set to begin this month. Moore said there are a few exceptions that won't go into effect until July 1, 2011 … most notably, the varicella requirement for full-time Tennessee college students and completion of two doses of hepatitis A vaccine spaced at least six months apart for kindergarten enrollment.

For this school year, Moore said, "The most change is for children enrolling in child care or pre-school facilities. We're requiring hepatitis B, pneumococcal conjugate vaccine and hepatitis A vaccine. We have resumed the requirement for the Hib (Haemophilus influenzae type B) vaccine. During the Hib shortage of 2008 through mid-2009, we suspended that requirement. Now that the shortage is over, we have reinstated the requirement."

Moore has set up a guideline page at http://health.state.tn.us/CEDS/required.htm with new dosing information and additional required vaccines outlined in bold followed by effective dates in italics. Requirements that remain unchanged are in regular type. For example, Moore said, the polio vaccine for children entering kindergarten is not boldfaced because it was previously required. However, she continued, there is a bold line attached to the vaccine stating, "final dose on or after the fourth birthday now required."

A new Certificate of Immunization, which is filled out by providers, has been modified to clearly outline the new requirements and includes a reference list of vaccines and intervals required in Tennessee plus a catch-up schedule. This certificate is mandatory for children to be enrolled in school or day care. Moore noted Tennessee law accepts only two types of exemptions for vaccines — religious or medical. "Physician Assistants and Advanced Practice Nurses can provide certificates of vaccine," she explained. However, Moore continued, "Only physicians or the Health Department can issue a certificate with a medical exemption." She added that such exemptions are rare and that children would still be required to have any vaccines not specifically contraindicated by a medical condition.

Moore said the rules take into account that children under 18 months would not have completed vaccine schedules before enrolling in day care or pre-school. "Children need to be up-to-date for their age at enrollment," she clarified. "Our new certificate has check boxes so the provider can easily indicate the level of completion."

By 18 months, Moore said, children should have completed all their required vaccines for child care. There are, however, several more vaccines needed at age four prior to enrolling in kindergarten. Infants and toddlers who are up-to-date for their age receive a certificate that remains valid until 19 months of age with the appropriate boxes checked. "We have really worked hard to make this a lot simpler and answer a lot of questions that were left unanswered by the old certificate," Moore said.

For children who are behind, Moore explained, "A child can be enrolled on a provisional basis while they catch up on their immunizations." She noted the Certificate of Immunization has an option to mark "temporary" and include an expiration date, which should include a grace period of one month past the vaccine due date. However, enforcement is really left up to the day care facility or school. Administrators are supposed to require parents to provide a new certificate before the old one expires.

One nice feature, Moore added, is that providers have the option to check off immunization completion for both pre-K and kindergarten for four-year-olds who have finished their shots. This keeps parents from having to come back for a second form before enrolling children in kindergarten as was previously required.

Another key difference between the old requirements and new are the expanded regulations for seventh graders. "In the past, the state has required that the records of rising seventh graders be checked for hepatitis B vaccine," Moore said. She added this is no longer necessary since a regulation that all children have this vaccine prior to kindergarten has been in place for a decade. "What we've added," she continued, "is a requirement for the Tdap booster, as well as verification that the child has had two doses of the varicella vaccine because when they came into kindergarten, they were only required to have one and now the CDC recommends two."

Despite a broad public awareness campaign, Moore said her department recognizes the new regulations for seventh graders would catch some parents and students by surprise. "The grace period is through the month of September so they have until October 1. This should be enough time since our schools start in August." Moore added there is an important secondary benefit of the new immunization requirements. "We know many preteens and young teenagers don't get routine physicals. This is a great opportunity to reach a very hard-to-reach population and offer other preventative services." In addition to the required immunizations, she suggested physicians discuss the meningitis and HPV vaccines and talk about healthy behaviors.

By next summer, young adults entering college will also be required to show proof of immunity to varicella. As with younger children, there are three options of proof outside the vaccine: serologic evidence, reliable history of reported illness, or diagnosis with a documented date.

By updating Tennessee's immunization requirements, Moore said, "This is going to dramatically improve the quality of health and safety of our schools."